WONCA Special Interest Group: Quaternary Prevention & Overmedicalization

Quaternary Prevention & Overmedicalization

A new WONCA Special Interest Group on Quaternary Prevention and Overmedicalization was approved by the WONCA Council in October 2016. Membership is open to interested family doctors. 

Introduction: Justification and Importance

“Medicine increasingly focuses on the problems that result from an excess of medical care, in particular overscreening and overdiagnosis. In a new framework or paradigm, based on patient doctor relationships, quaternary prevention (P4) describes the protection of patients from diagnostic tests, interventions and treatments that offer no benefit for overall morbidity or mortality for the individual, and may cause physical or psychological harm. It includes the protection of patients from misled well-meaning doctors and from a system in which the commercial interests of pharmaceutical and diagnostic companies, and governments working in a marketised model of health care, that can distort care, medicalize normal life and waste resources”. Jamoulle M, Mangin D (not published).


The original definition of Quaternary Prevention was formulated in 1986: Action taken to identify patient at risk of overmedicalization, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable.

The concept of quaternary prevention is grounded in the ethical principles of medicine, an epistemological understanding of a paradigm crisis or struggle that is challenging the predominant biological paradigm in health, and the realization of a movement that includes citizens, patients, care providers and public health policies.

Quaternary prevention provides a complex but necessary approach oriented to provide person -focused care; promote equity in healthcare; prevent overdiagnosis, unnecessary interventions, and avoid harm: and so, in few words, to humanize medicine. All the efforts within this global movement combine ethical sustainability with critical thinking, to oppose the vision of health as a commodity.

Understanding of the power of the socio-cultural determinants of health requires family and community medicine to re-think the approach to healthcare and to work in a huge network with all the relevant actors (persons/consumers, community stakeholders, providers, health managers, and politicians). Quaternary prevention applies primarily to the interpersonal level in the patient-doctor encounter. Confronting overdiagnosis and overuse are complementary issues with a different focus.

In the context of this broad approach it is clear that the tasks of quaternary prevention go beyond preventive activity and its conceptual scope can underpin all aspects of everyday medical activity in the face of uncertainty.

Overdiagnosis is understood to occur when an asymptomatic person is identified as having a disease, which would never harm them in their lifetime.

Convenor / Chair

Dr Miguel Pizzanelli - SIG Quaternary Prevention and Overmedicalization

My name is Miguel Pizzanelli Báez. I was born in Montevideo in 1962. With Virginia my wife and dear partner, we share raising three children. At this moment we live in Florida, Uruguay. Since 1996 I spent almost all my medical practice time in small rural areas. For seven years (from 2003 to 2010) we had the experience of living and working in a small rural village of 1500 inhabitants. I have varied interests, reading, I try to play several musical instruments in a self-taught way. Hobbies: music, trekking, photography, web-blogs editor.
I am general practitioner (family and community medicine) from 2003. I was part of the first generation of family and community medicine residents trained in Uruguay. I call this the zero generation (remembering of hard times that passed).

I use to disseminate contents in various topics: quaternary prevention, rural medicine, critical thinking development. Quaternary prevention is a concept that defines an attitude ethically center oriented to provide health care focusing on persons trying to share health decisions with them in order to avoid overmedicalization.

Since 2012 I began to actively participate in the society of family and community medicine in Uruguay and from that place in CIMF / WONCA. My role leading dissemination and applied of quaternary prevention concept pushed me to lead quaternary prevention working groups, first in my country later in Iberoamerican region and now in WONCA. My interest in classification and systematic terminologies makes me accept the invitation to participate in WONCA International Classification Committee in the quality of associate member from November 2014 up to date. Since 2008 we develop research focus on Barbara Starfield’s Primary Care Assessment Tool in Uruguay. I participate actively in national regional and international CIMF WONCA Conferences (Praga 2013, Montevideo 2015, and Rio de Janeiro 2016).

I think we need to fight both an individual and collective fight. The Individual fight to set collective interests over personal ones. Only through the collective work of all the family doctors and communities together all over the world we will achieve "real" Primary Care: comprehensive health care, equity, and people-centered health care, focus on health better than illness, making reality the utopia of health for all in a better world.

email convenor

Co-Convenor or other office bearers

Executive Members

Membership Open?

Vision and Mission of WONCA SIG on Quaternary Prevention & Overmedicalization

To create an international network to support ongoing activities and promote dissemination and skills to apply the concepts all over the world.

Objectives of the WONCA SIG on Quaternary Prevention & Overmedicalization

- Facilitate cooperation among societies and professionals in order to promote knowledge exchange and expertise.
- Promote critical attitude and critical thinking about the profound conflicts of interest that undermine medical activities.
- Promote critical literature review networks
- Promote quaternary prevention focus on research questions and projects
- Give support to national societies to include quaternary prevention and overmedicalization in the undergraduate and graduate programs.
- Promote understanding of over medicalisation and the need for quaternary prevention in the global mass media.
- Promote cooperation between existing resources and organizations (Universities facilities, Pharmacovigilance, Cochrane reviews, Journals interest, qualitative research skills, population participation, mass media presence, Choosing Wisely, Preventing Overdiagnosis)
- Organize WONCA activities oriented to disseminate the concept and share experiences.
- Resources would come from WONCA members, grants, awards, web services and create a foundation.

>link to full document


Relevant Resources

Silva AL, Mangin D, Pizzanelli M, Jamoulle M, Wagner HL, Silva DH et al. Manifesto de Curitiba: pela Prevenção Quaternária e por uma Medicinan sem conflitos de interesse. Rev Bras Med Fam Comunidade. 2014;9(33):371-374. Disponível em http://dx.doi.org/10.5712/ rbmfc9(32)1006

SUMEFAC/ Grupo de Trabajo en Prevención Cuaternaria. Propuesta de actividades Seminario Internacional Prevención Cuaternaria. Actividades Preparatorias al 4º Congreso Iberoamericano DE Medicina Familiar y Comunitaria, marzo 2015 [base de datos en Internet]*. Uruguay: SUMEFAC – Pizzanelli M.; Julio 2015, [acceso 21 de julio de 2016]. Disponible en: https://drive.google.com/file/d/0B2tjwHv1enqDcXR1Vkpmb2pFbDA/view?usp=sharing